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Waste Tire Su. ., ay & Inspection Report, Inspection Report Number ■ <br /> =ger State CIWMB California I 1 — 114 3 7 3 9 <br /> Californialne grat d'Wase81 eManagementBoard Survey Fow 04/04) rm - Page 1 <br /> Part A-Survey__- BLUE OR BLACK INK PEN <br /> - ---- -- --------- <br /> Business Profile Inspection Details <br /> TPID- ` r+, �y _ Inspection Type (Fill one) <br /> Site <br /> Site Suffix: }U� 19 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Iry C 'f�k� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> (� Inspected By Inspector <br /> L1T� `��tAA Servi ce- hoc. � - Ur <br /> Physical Address 1 1 I Ren �5�- <br /> IS its s . sc�u.lkp­ fLA. <br /> CCk ��1 ► %31r) Inspection Date V I l <br /> 1 J Time In Time Out <br /> Business Rep Title OAM z O Q AM <br /> 2 o C ` f A PM • PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger I&Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler • Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude — 0 Planned • OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) Fd 4b <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other ' <br /> 9rVi tzse.pt�t I sa Ips <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V A JHAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB M <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> I <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators p In Compliance - No Violations <br /> 1010 Other: § <br /> Comments 1Le�_1.� � LU (7 DeAcif CCS. 1, on A)n�S A,, CLT)(� <br /> No v i D k Inn5 0c acus 0� coo CQFn . -- --- <br /> Inspection Form Included: 0 -19 <br /> e-, <br /> Comments Included: * -- -- -- 7 , 0MI.N0 <br /> � �UgJ_ 31 !b <br /> ne p s Sign ture Phone Number InspE'r', ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect X le A M P i 1 ' 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />